Current outcomes of blunt open pelvic fractures: how ...

Original article

Current outcomes of blunt open pelvic fractures:

how modern advances in trauma care may

decrease mortality

Sammy S Siada, James W Davis, Krista L Kaups, Rachel C Dirks, Kimberly A Grannis

Department of Surgery,

Community Regional Medical

Center, University of California,

San Francisco-Fresno, Fresno,

California, USA

Correspondence to

Dr Sammy S Siada, Department

of Surgery, Community Regional

Medical Center, Fresno, CA

93721, USA; s? siada@?fresno.?

ucsf.e? du

This paper was presented as

a poster at the 75th annual

meeting of the American

Association for the Surgery of

Trauma, Sep 2016.

Received 23 October 2017

Revised 22 November 2017

Accepted 27 November 2017

Abstract

Background Open pelvic fracture, caused by a blunt

mechanism, is an uncommon injury with a high mortality

rate. In 2008, evidence-based algorithm for managing

pelvic fractures in unstable patients was published by the

Western Trauma Association (WTA). The use of massive

transfusion protocols has become widespread as has the

availability and use of pelvic angiography. The purpose

of this study was to evaluate the outcome of open pelvic

fractures in association with related advances in trauma

care.

Methods A retrospective review was performed, at

an American College of Surgeon verified level I trauma

center, of patients with blunt open pelvic fractures

from January 2010 to April 2016. The WTA algorithm,

including massive transfusion protocol, and pelvic

angiography were uniformly used. Data collected

included injury severity score, demographic data,

transfusion requirements, use of pelvic angiography,

length of stay, and disposition. Data were compared with

a similar study from 2005.

Results During the study period, 1505 patients with

pelvic fractures were analyzed; 87 (6%) patients had

open pelvic fractures. Of these, 25 were from blunt

mechanisms and made up the study population. Patients

in both studies had similar injury severity scores, ages,

Glasgow Coma Scale, and gender distributions. Use of

angiography was higher (44% vs. 16%; P=0.011) and

mortality was lower (16% vs. 45%; P=0.014) than in the

2005 study.

Conclusions Changes in trauma care for patients

with open blunt pelvic fracture include the use of an

evidence-based algorithm, massive transfusion protocols

and increased use of angioembolization. Mortality

for open pelvic fractures has decreased with these

advances.

Level of evidence Level IV.

pelvic fractures despite significant advancements in

the care of these injuries.

The Western Trauma Association (WTA)

published an algorithm for Management of Pelvic

Fractures with Hemodynamic Instability in 2008,

which provided an evidence-based schema for

this injury.6 The algorithm emphasizes the importance of a multidisciplinary approach with trauma

surgery, orthopedics, and interventional radiology.

It also addresses diagnostic evaluation, exclusion

of intra-abdominal injury, pelvic stabilization,

and decisions concerning surgical options and

angiography.

The management of coagulopathy has also

evolved since the study by Dente et al was

published. Implementation of a massive transfusion protocol (MTP) with 1:1:1 ratio of packed red

blood cells (PRBC) to fresh frozen plasma (FFP)

to platelets has been shown to reduce mortality in

patients with traumatic hemorrhage.7¨C9 This is due

to expeditious product availability and aggressive

transfusion of blood products that enables quick

restoration of intravascular volume and treatment

of coagulopathy.

Additionally, the use of pelvic angiography

and embolization has increased in the last decade

and has been found to be an effective adjunct for

control of pelvic fracture hemorrhage.10 Another

advancement has been the advent of hybrid operating rooms (ORs), which are increasingly being

used in trauma.11

The purpose of this study was to examine

outcomes for blunt open pelvic fractures in the

current era and compare them with previously

reported data. We hypothesize that the changes in

care of patients with open pelvic fractures have led

to a decreased overall mortality.

Methods

Background

To cite: Siada SS, Davis JW,

Kaups KL, et al. Trauma

Surg Acute Care Open

2017;2:1¨C4.

Open pelvic fracture is a morbid injury and very

often is a lethal one. Historically, mortality rates

have been reported to range from 5% to as high as

50%.1¨C4 Early mortality is related to exsanguinating

hemorrhage and late mortality is generally due to

pelvic sepsis.

In 2005, Dente and colleagues retrospectively

analyzed patients who sustained open pelvic fractures as a result of blunt mechanism between 1995

and 2004.5 The overall mortality in that series was

45%. Since that study was published, there has been

a paucity of published data on the outcomes of open

A retrospective review was performed on patients

admitted to Community Regional Medical Center

(CRMC), an ACS-verified level 1 trauma center,

from January 1, 2010 through April 30, 2016.

Patients with open pelvic fractures from blunt

mechanism were identified from the trauma registry

and were included in this study. Data collected

included the following: age, sex, injury severity

score (ISS),12 Glasgow Coma Scale (GCS), Gustilo

grade of soft tissue injury, orthopedic management,

use of pelvic angiography, operative management,

hospital length of stay (LOS), transfusion requirements in the first 24 hours, and final disposition.

Siada SS, et al. Trauma Surg Acute Care Open 2017;2:1¨C4. doi:10.1136/tsaco-2017-000136

1

Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2017-000136 on 27 December 2017. Downloaded from on September 17, 2024 by guest. Protected by

copyright.

Open Access

Table 1

Table 3

Gustilo-Anderson¡¯s classfication

Type

Definition

I

II

Clean wound, 1 cm but 10 cm in length, fractures open for >8 hours

ISS

GCS

Age (years)

Males

2005

2016

30

29

12

11

39

42

68%

68%

P value

0.87

0.67

¨C

0.98

GCS, Glasgow coma scale; ISS, injury severity score.

Patients with penetrating injuries and closed fractures were

excluded.

Patients were initially evaluated in the emergency department

(ED) with a collaborative team of in-house residents, fellows,

and attending physicians from the departments of trauma

surgery and emergency medicine. The WTA algorithm is the

guideline by which patients with pelvic fractures are treated at

CRMC. The initial diagnosis of pelvic fracture was made by a

pelvic X-ray obtained during the primary survey. Hemodynamically stable patients were taken to the CT scanner for an

abdominopelvic scan and if contrast extravasation in the pelvis

was visualized, the patient was sent for pelvic angiographic and

possible embolization. The MTP was initiated in patients who

were hemodynamically unstable (any systolic blood pressure

less than 90). A focused assessment with sonography for trauma

(FAST) or diagnostic peritoneal lavage was performed to exclude

intra-abdominal injury. Patients were taken to the OR for laparotomy if the FAST was positive and were sent for angiography if

the FAST was negative. Pelvic binders were placed when patients

have open book fractures and were hypotensive.

FAST was readily available and used when indicated. Pelvic

stabilization in the ED, when performed, involved the use of a

commercially available external pelvic stabilizer. A MTP designed

to optimize the goal of a 1:1:1 PRBC to FFP to platelet ratio was

uniformly used. There was 24 hours availability of pelvic angiography, which was performed in the angiography suite or hybrid

OR by an interventional radiologist.

The degree of soft tissue injury was defined using the Gustilo-Anderson and Faringer classifications (tables 1 and 2).13 14

The data obtained in this study were compared with the 2005

study by Dente and colleagues. Using the 2005 study as a historical control group, comparisons were made between the patient

demographics, ISS, LOS, injury severity and classification, use of

fecal diversion, and overall mortality rate. Dichotomous variables

were compared using ¦Ö2 analysis with a significance attributed to

a P value of ................
................

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